Once you’ve graduated from optometry school, it’s time to put everything you learned into practice. You may still be figuring out how to manage complex patient cases and seeing ocular disease for the first time independently. However, there’s a much bigger world of health care out there and now you’re a part of it. What kind of optometrist do you want to be? This article will give you some topics in public health to think about as you forge your career path as a clinician.
Health disparities are defined by Healthy People 2020 as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.” In “Making Eye Health a Population Health Imperative: Vision of Tomorrow,” a report released by the National Academies of Science, Engineering, and Medicine (NASEM), three of the nine recommendations specifically target health equity and health disparities with respect to eye health. When interacting with patients, it’s crucial to expand your thought process and more comprehensively meet the needs of each patient. Here are just four questions to consider:
- Are you thinking about potential health outcomes of your patients that could be a result of health disparities?
- Do your patients have any chronic conditions whose severity could be lessened?
- Do your treatment and management plans take into account the patient’s values and preferences, particularly given potential barriers to access to care?
- What are your implicit biases and what can you do to make sure this minimizes any negative impact on patient care?
This is just to start, but these questions are necessary when developing a plan of care.
One of my patients at a community health center in Boston is a 45 year old black female with a longstanding, complicated history of multiple sclerosis with previous episodes of optic neuritis in the left eye. When I first met her, she presented with acute granulomatous anterior uveitis in the right eye, of which we suspected syphilis as the etiology. She was justifiably concerned with the status of her right eye and was diligent in returning for care.
However, she was facing very real obstacles to taking care of herself. She was currently living in a shelter and was at risk for being transferred 30-45 minutes outside Boston. She and I discussed this and I wrote a letter on her behalf to request a transfer to a shelter in closer proximity to the health center. We had very open and candid discussions about her health status, living situation, and the ways in which I could assist her. It was important to approach these discussions from a judgement-free perspective and lead with empathy to avoid perpetuating health disparities.
Social Determinants of Health
Social determinants of health—"conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks”—are inextricably linked to health disparities. Healthy People 2020 identified five key determinants:
- Economic stability
- Social and community context
- Health and health care
- Neighborhood and built environment
Among these, there are three more specific determinants that are worthy of deeper consideration for optometrists.
Socioeconomic status is “the social standing or class of an individual or group. Examinations of socioeconomic status often reveal inequities in access to resources, plus issues related to privilege, power and control.” SES is typically measured via education level, income, or occupation. How do you think a patients’ education level, income, or occupation could be affecting their ocular health and access to care? Are you adapting your approach to clinical care accordingly? I often use 2-3 iterations of explanations for ocular conditions during patient education. I try to use verbal and non-verbal cues to gauge whether those explanations are sufficient and adjust accordingly. I also have discussions with patients regarding exam costs and how we can reach a mutually agreed upon management plan. This is a core part of how I try to deliver patient-centered care.
Neighborhood influences and social capital refer to a person’s surroundings and how that impacts health outcomes. What is the surrounding built environment? Is there green space that is safe for recreation and play in the neighborhood? Is there access to fresh food or does your patient live in a food desert, where residents cannot easily access fresh foods due to a lack of grocery stores, markets, and other resources? How can someone control their diet if access to fresh food is restricted? What resources are available in your area to counteract geographical constraints on food sources? There are delivery services from grocery stores or online retailers, such as Peapod through Stop & Shop or Prime Pantry through Amazon. A simple Google search could reveal additional resources for those with limited income, such as local food pantries or volunteer/religious organizations. For example, Daily Table, a non-profit organization in Dorchester, MA , is dedicated to providing healthy, affordable food to all and they have partnered with food suppliers to provide excess food or special pricing in order to accomplish this
Social capital refers to the “resources garnered through social connections, networks, and support among communities.” What type of support do your patients have access to? Family? Friends? Community members? Does this impact their ability to visit doctors? Does it impact their mental health? Are you engaged with the community where you practice and are you aware of local resources that could benefit your patients? A 2018 JAMA article found that those Medicare beneficiaries with smaller social networks were less likely to have cataract surgery. Knowing about this correlation, I’ve started to discuss social support when referring patients for surgical procedures to identify potential barriers to care. Furthermore, when I was practicing low vision in central Massachusetts, I would often visit low vision support groups in the surrounding areas. My objective was to serve as a resource to the group, but those experiences gave me a wealth of information about the local resources that I could pass along to my patients.
Health Reform and Policy
Inadequate access to health care, financial barriers to affording care, and escalating health care costs in the US have prompted health reform initiatives. The most recent and significant health reform was the Affordable Care Act, signed into law in 2010. The main objectives of the law were to increase access to health insurance, reduce health care costs, and improve quality, safety, efficacy, and efficiency of medical care.
Additionally, a new approach to Medicare payment reform was enacted as part of the Social Security Act in 2015. The Medicare Access and CHIP Reauthorization Act (MACRA) created the Quality Payment Program (QPP), which includes the Merit Based Incentive Payments System (MIPS) and alternative payment models (APMs). These programs may or may not impact your optometric practice.
As of now, these programs are solely for patients with Medicare Part B. However, the thought in health care circles is that if this is successful, private insurance companies may follow suit. What this could mean for optometrists is a shift toward pay for performance, rather than fee for service. The QPP holds clinicians responsible for performance on quality measures, metrics on promoting interoperability, improvement activities, and cost, and optometrists are included as part of this program. As a clinician, it is important to stay up to date on developing health policy and how that could impact your patients and your practice. I have been actively engaged in the implementation of MIPS in the New England College of Optometry Center for Eye Care for the past three years. We have worked diligently to gather data on quality metrics, develop a culture of quality improvement, and ensure that we are technologically poised to meet the needs of tomorrow’s optometric practice. If MIPS expands to private payers, we will be fully ready. Will you?
I hope this provides food for thought as you participate in patient care and professional activities. Please share your thoughts and experiences in the comments below!